NC0047091_Permit (Issuance)_20131214

NPDES DOCUMENT SCANNINS COVER :MEET
NPDES Permit: NC0047091
Silver Maples WWTP
v.-
Document Type: Permit Issuance
Wasteload Allocation
Authorization to Construct (AtC)
Permit Modification
Speculative Limits
Compliance
Instream Assessment (67B)
Environmental Assessment (EA)
Permit
History
Document Date: December 14, 2013
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NCDE R
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Water Quality Programs
Pat McCrory Thomas A. Reeder John E. Skvarla, III
Governor Director Secretary
December 14, 2013
Chester G. DeBoard, Jr.
KBI, LLC
Silver Maples Mobile Estates
2812 Plantation Road,N.W.
Concord, North Carolina 28027
Subject: NPDES PERMIT ISSUANCE
Permit Number NCO047091
Silver Maples Mobile Estates W WTP - Class II
Cabarrus County
Dear Mr. Deboard:
Division personnel have reviewed and approved your application for renewal of the subject
permit. Accordingly, we are forwarding the attached final NPDES discharge permit. This permit is
issued pursuant to the requirements of North Carolina General Statute 143-215.1 and the
Memorandum of Agreement between North Carolina and the U.S. Environmental Protection
Agency dated October 15, 2007 (or as subsequently amended).
If any parts, measurement frequencies or sampling requirements contained in this permit are
unacceptable to you, you have the right to an adjudicatory hearing upon written request within
thirty (30) days following receipt of this letter. This request must be in the form of a written
petition, conforming to Chapter 150B of the North Carolina General Statutes, and filed with the
Office of Administrative Hearings (6714 Mail Service Center, Raleigh, North Carolina 27699-
6714). Unless such demand is made, this permit shall be final and binding.
Please take notice that this permit is not transferable. This permit does not affect the legal
requirements to obtain other permits which may be required by the Division of Water Resources or
permits required by the Division of Land Resources, Coastal Area Management Act, or any other
Federal or Local governmental permits which may be required.
If you have any questions or need additional information, please do not hesitate to contact
Maureen Kinney of my staff at [phone].
Sinc rely,
Thomas A. Reeder
cc: Central Files
NPDES Unit Files
Mooresville Regional Office, Surface Water Protection Section
1617 Mail SepAce center,Raleigh,North Carolina 27699-1617
Location:512 N.Salisbury St.Raleigh,North Carolina 27604
Phone:[phone] Fax:[phone]
Internet::%w ncwatemualitv.om
An Equal CpportunityWrumative Action Employer

Permit NC0047091
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER RESOURCES
PERMIT
TO DISCHARGE WASTEWATER UNDER THE
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provisions of North Carolina General Statute 143-215.1, other lawful
standards and regulations promulgated and adopted by the. North Carolina Environmental
Management Commission, and the Federal Water Pollution Control Act, as amended,
KBI, LLC
is hereby authorized to discharge wastewater from a facility located at the
Silver Maples Community WWTP
2812 Plantation Road
Concord
Cabarrus County
to receiving waters designated as the Rocky River in the Yadkin-Pee Dee River Basin, in
accordance with effluent limitations, monitoring requirements, and other conditions set forth in
Parts I, II, III and IV hereof.
This permit shall become effective January 1, 2013.
This permit and authorization to discharge shall expire at midnight on November 30, 2018.
Signed this day December 14, 2013.
IZ-721
Thom s . Reeder, Director
Di4 on of Water Resources
By Authority of the Environmental Management Commission
Page 1 of 7

Permit NC0047091
SUPPLEMENT TO PERMIT COVER SHEET
All previous NPDES Permits issued to this facility, whether for operation or discharge are hereby
revoked. As of this permit issuance, any previously issued permit bearing this number is no
longer effective. Therefore, the exclusive authority to operate and discharge from this facility
arises under the permit conditions, requirements, terms, and provisions included herein.
KBI, LLC is hereby authorized to:
1. . Continue to operate an existing 0.040 MGD wastewater treatment facility that includes the
following components:
➢ Bar screen
➢ Grit/Storage tank
➢ Primary clarifier
➢ Aeration/Reaeration
➢ Final clarification
➢ Aerated sludge holding tank
➢ Chlorination
➢ Dechlorination
➢ Effluent flow measurement
2. This facility is operating at 2812 Plantation Road, located at the Silver Maples Mobile
Estates in Cabarrus County
3. Discharge from said treatment works at the location specified on the attached map into the
Rocky River, currently classified C waters in sub-basin 03-07-11 of the Yadkin-Pee Dee
River Basin.
Page 2 of 7

Permit NCO047091
PART
A. (1.) EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS
During the period beginning on the effective date of this permit and lasting until expiration,
the Permittee is authorized to discharge treated wastewater from outfall 001. Such discharges
shall be limited and monitored' by the Permittee as specified below:
EFFLUENT CHARACTERISTICS LIMITS MONITORING REQUIREMENTS
Monthly Daily Measurement . Sample Sample
Parameter Code Average Maximum- Frequency Type . Location
Flow 50050 0.040 MGD Continuous Recording Influent or Effluent
5-day,20°C
C0310 13.0 mg/L 19.5 mg/L Weekly Composite Effluent
C031
Total Suspended Solids C0530 30.0 mg/L 45.0 mg/L Weekly Composite Effluent
NH3 as N 2/Month Composite Effluent
C0610
Fecal Coliform(geometric mean) 200/100 ml 400/100 ml Weekly Grab Effluent
31616
pH Not<6.0 nor>9.0 Weekly Grab Effluent
00400 Standard Units
Temperature 00010 Weekly Grab Effluent
Total Residual Chlorine 50060 28.0 µg/L 2/Week Grab Effluent
Total Phosphorus(TP)
C0665 Quarterly Grab Effluent
Total Nitrogen(TN)
C0600 Quarterly Grab Effluent
Footnote:
1. No later than 90 days from the effective date of this permit, begin submitting discharge
monitoring reports electronically using NC DWR's eDMR application system. See Special
Condition A (3.).
2. The Division shall consider all effluent"CRC values reported below 50 ug/1 to be in
compliance with the permit. However, the Permittee shall continue to record and submit all
values reported by a North Carolina certified laboratory(including field certified), even if
these values fall below 50 µg/l.
All samples collected should be from a representative discharge event.
THERE SHALL BE NO DISCHARGE OF FLOATING SOLIDS OR VISIBLE FOAM IN OTHER THAN TRACE AMOUNTS.
Page 3 of 7

Permit NCO047091
A. (2.) CONNECTION NOTIFICATION AND RESCISSION REQUEST
Facility is required to notify Mooresville Regional Office and the NPDES Unit in Raleigh when
the following events occur:
1. Silver Maples Mobile Estates is connected to the City Water and Sewer lines.
2. Silver Maples Mobile Home Park is no longer discharging treated wastewater to the Rocky
River.
3. KBI, LLC may request that NPDES Permit NCO047091 be rescinded.
A. (3.)ELECTRONIC REPORTING OF DISCHARGE MONITORING REPORTS
Proposed federal regulations require electronic submittal of all discharge monitoring reports
(DMRs) and specify that, if a state does not establish a system to receive such submittals, then
permittees must submit DMRs electronically to the Environmental Protection Agency (EPA).
The Division anticipates that these regulations will be adopted and is beginning implementation
in late 2013.
NOTE: This special condition supplements or supersedes the following sections within Part II of
this permit (Standard Conditions for NPDES Permits):
• Section B. (11.) Signatory Requirements
• Section D. (2.) Reporting
• Section D. (6.) Records Retention
• Section E. (5.) Monitoring Reports
1. Reporting [Supersedes Section D. (2.) and Section E. (5.) (a)l
Beginning no later than 90 days from the effective date of this permit, the permittee shall
begin reporting discharge monitoring data electronically using the NC DWR's Electronic
Discharge Monitoring Report (eDMR) internet application.
Monitoring results obtained during the previous month(s) shall be summarized for each
month and submitted electronically using eDMR. The eDMR system allows permitted
facilities to enter monitoring data and submit DMRs electronically using the internet. Until
such time that the state's eDMR application is compliant with EPA's Cross-Media Electronic
Reporting Regulation (CROMERR), permittees will be required to submit all discharge
monitoring data to the state electronically using eDMR and will be required to complete the
eDMR submission by printing, signing, and submitting one signed original and a copy of the
computer printed eDMR to the following address:
NC DENR/ DWR/ Information Processing Unit
ATTENTION: Central Files / eDMR
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Page 4 of 7

Permit NC0047091
If a permittee is unable to use the eDMR system due to a demonstrated hardship or due to the
facility being physically located in an area where less than 10 percent of the households have
broadband access, then a temporary waiver from the NPDES electronic reporting
requirements may be granted and discharge monitoring data may be submitted on paper DMR
forms (MR 1, 1.1, 2, 3) or alternative forms approved by the Director. Duplicate signed
copies shall be submitted to the mailing address above.
Requests for temporary waivers from the NPDES electronic reporting requirements must be
submitted in writing to the Division for written approval at least sixty (60) days prior to the
date the facility would be required under this permit to begin using eDMR. Temporary
waivers shall be valid for twelve (12) months and shall thereupon expire. At such time,
DMRs shall be submitted electronically to the Division unless the permittee re-applies for
and is granted a new temporary waiver by the Division.
Information on eDMR and application for a temporary waiver from the NPDES electronic
reporting requirements is found on the following web page:
http://portal.nedenr.org/web/wq/admin/bop/ipu/edmr
Regardless of the submission method, the first DMR is due on the last day of the month
following the issuance of the permit or in the case of a new facility, on the last day of the
month following the commencement of discharge.
2. Signatory Requirements [supplements Section B. (11.) (b) and supersedes Section B.
(IL) (d))
All eDMRs submitted to the permit issuing authority shall be signed by a person described in
Part II, Section B. (1 1.)(a) or by a duly authorized representative of that person as described
in Part 1I, Section B. (I I )(b). A person, and not a position, most be delegated signatory
authority for eDMR reporting purposes.
For eDMR submissions, the person signing and submitting the DMR must obtain an eDMR
user account and login credentials to access the eDMR system. For more information on
North Carolina's eDMR system, registering for eDMR and obtaining an eDMR user account,
please visit the following web page: http://portal.ncdenr.or web/wq/admin/bov-/ipu/edmr
Certification. Any person submitting an electronic DMR using the state's eDMR system
shall make the following certification [40 CPR 122.22]. NO OTHER STATEMENTS OF
CERTIFICATION WILL BE ACCEPTED:
"I certify, under penalty of law, that this document and all attachments were prepared under
my direction or supervision in accordance with a system designed to assure that qualified
personnel properly gather and evaluate the information submitted Based on my inquiry of
the person or persons who manage the system, or those persons directly responsible for
Page 5 of 7

Permit NCO047091
gathering the information, the information submitted is, to the best of my knowledge and
belief, true, accurate, and complete. I am aware that there are significant penalties for
submitting false information, including the possibility offines and imprisonment for knowing
violations."
3. Records Retention [Supplements Section D. (6.)l
The permittee shall retain records of all Discharge Monitoring Reports, including eDMR
submissions. These records or copies shall be maintained for a period of at least 3 years from
the date of the report. This period may be extended by request of the Director at any time [40
CFR 122.41].
Pa,-e 6 of 7

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KBI, LLC Facility
Silver Maples Community WWTP f
Location �->-- -�--•-,X�
Count v: Cabarrus Stream Class: C (not to scdlel
Receiving Stream: Rocky River Sub-Basin: 03-07-11
Latitude: 35022'12" Grid/Quad: Harrisburg
Longitude: 80'41'00" Huca: 03040105 North NPDESPermit: NC0047091

lssi �e �a I llQ 113
Independent Tribune
Account Number
Advertising Affidavit -
3611028
PO Box 968
Hickory, NC 28603 Date
October 30,2013
NCDENR/DWQ
1617 MAIL SERVICE CENTER
RALEIGH,NC 27699-1617
Date Category Description Ad Number - Ad Size
10/30/2013 Legal Notices Public Notice North Carolina Environmental Managemen 0003138642 1 x 46 L
Public Notice
North Carolina Environmental Management
commission/NPDES Una - Publisher of
1617 Mal Service Center
Raleigh,NC 27699-1617
Notice of Intent to Issue a Independent Tribune
NPDES Wastewater Permit
The North Carolina Environmental Management Cabarrus County
Commission proposes to issue a NPDES wastewa .
ter discharge permit to the person(s)listed below.
Written comments regarding the proposed permit
will be accepted until 30 days after the publish
date of this notice.The Director of the NC Division of Water Resources(DWR)may hold a public hear-
ing should there be a significant degree of public Before the undersigned,a Notary Public of Catawba County,North
interest Please mail comments and/or informs- Carolina,duly commissioned,.qualified,and authorized by law to
tion requests to DWR at the above address. Inter-
ested persons may visit the DWR at 512 N.Salis. administer oaths,in said County and State;that he/she is authorized to
bury Street, Raleigh, NC to review information on
file.Additional information on NPDES permits and make this affidavit and sworn statement;that the notice or other legal
this notice may be found on our website: advertisement,a copy of which is attached hereto,was published in the
htto://oortel.ncdenr.org/web/wq/swp s n des/
calendar, or by calling {919_07:6390. Corning Independent Tribune on the following dates:
Incorpored requested renewal of permit
NCOOBGI69 for Midland Plant WWTP in Cabanus
County;this facility discharge is treated industrial 10/30/2013
wastewater and stormvrater to an unnamed trib-
utary to Muddy Creek, an unnamed tributary to
Clear Creek,and Rocky River,Yadkin River Basin.
Carolina Water Systems, Inc of NC has applied for
renewal of permit N00051632 for Huntwick Subdi. and that the said newspaper in which such notice,or legal advertisement
vision WWTP;Captious County.This permitted fa-
cility discharges treated wastewater to the Fuda was published,was a newspaper meeting all the requirements and
Creek; Yadkin Pee-Dee River Basin. NBI, LLC has qualifications of Section 1-597 of the General Statutes of North Carolina.
applied far renewal of NCO047091 for Silver Maple
Mobile Estates WWTP in Cabarrus County. This
permitted facility discharges treated wastewater • n
into Rocky River,Yadkin-Pee Dee River Basin. Cur- 1 C
rently total residual chlorine is water quality fmit-
ed.This discharge may affect future allocations in Assistant Bookkeeper
this portion of the watershed. Chemical Special.
ties, Inc requested renewal of permit NC0006351
for their WWTP in Caharrus County: this facility Newspaper reference.0003138642
discharge is treated industrial wastewater to
Rocky River.Yadkin River Basin.
PUBLISH:October 3%2013.
Sworn to and subscribed before me,this 30 day of ZDII n'1 erne
` o�MA
Nomry Publicej� ,,\O TA
q � O T
My Commission expires: i a 0�y �gL`G =C)..-
,Bq C UN�. .
THIS IS NOT A BILL. PLEASE PAY FROM INVOICE. THANk Y0 rrrr�`��

FACT SHEET FOR EXPEDITED PERMIT RENEWALS
This form must be completed by Permit Writers for all expedited permits which do not
require full Fact Sheets. Expedited permits are generally simple 100% domestics (e.g.,
schools, mobile home parks, etc) that can be administratively renewed with minor changes,
but can include facilities with more complex issues (Special Conditions, 303(d) listed water,
toxicity testing, instream monitoring, compliance concerns).
Basic Information for Expedited Permit Renewals
Permit Writer/Date Maureen Kinney 10/18/2013
Permit Number NCO047091
Facility Name Silver Maple Mobile Estates W WTP
Basin Name/Sub-basin number Yadkin Pee Dee 03-07-11
Receiving Stream Rocky River
Stream Classification in Permit C
Does permit need Daily Max NF13 limits? No
Does permit need TRC limits/language? Yes No
Does permit have toxicity testing? Yes No
Does permit have Special Conditions? Yes No—Connection Notification
Does permit have instream monitoring? Yes No
Is the stream impaired (on 303(d) list)? For Yes No
whatparameter?
Any obvious compliance concerns? BOD violations/assessment for March 2013
Fecal violation/assessment for June 2013
Any permit mods since lastpermit? A correction to the BOD Daily Max last renewal
Current expiration date 11/30/20 13
New expiration date 11/30/2018
Comments received on Draft Permit? A municipal sewer line (City of Concord) is
approximately 150-200 feet from this facility.
The facility is prone to flooding with the
exception of the blower motor units and
electrical control box that has been placed on an
elevated platform.
The park manager is in the process of completing
the requirements for the City of Concord for
connection,there is no completion date at this
time. MRO recommends renewal as requested.
Please note the following modifications to this draft:
• added parameter codes to Section A.(1.) Effluent Limitations and
Monitoring Requirements

CCeA
SOC Priority Project: No
To: NPDES Unit
Water Quality Section
Attention: Charles Weaver
Date: August 19, 2013
NPDES STAFF REPORT AND RECOMMENDATIONS
County: Cabarrus
NPDES Permit No.: NCO047091
PART I - GENERAL INFORMATION
1. Facility and Address: KBI, LLC J /7
Silver Maples Mobile Estates
2812 Plantation Road, N.W.
Concord, N.C. 28027 AUG 2 6 2013
POlNNT ATFR
2. Date of Investigation: August 13, 2013 so UR-Fe�A�ny
RANCH
3. Report Prepared By: Wes Bell, Environmental Specialist
4. Person Contacted and Telephone Number: Chester G. Deboard, Jr. [phone]
5. Directions to Site: From the junction of Hwy. 29 and Pitt School Road, north of the Town
of Harrisburg, travel west on Pitt School Road approximately 1 mile to the junction of
Plantation Road. Turn left on Plantation Road and proceed to the intersection with Darwin
Road. Turn left on Darwin Road and the WWTP will be located at the end of this road
(gravel driveway).
6. Discharge Point(s), List for all discharge Point:
Outfall 001
Latitude: 350 22' 12"
Longitude: 800 41' 00"
See USGS Map included with the renewal application for specific location of the outfall.
USGS Quad No.: F 16 SW Harrisburg,NC
7. Receiving Stream or Affected Surface Waters: Rocky River
a. Classification: C
b. River Basin and Subbasin No.: Yadkin 03-07-11
C. Describe receiving stream features and pertinent downstream uses: This receiving
stream has considerable flow. There is an additional discharge (Carolina Village
MHP - NC0063762) located downstream of this facility. General C classification
uses downstream.

Page Two
PART II - DESCRIPTION OF DISCHARGE AND TREATMENT WORKS
1. a. Volume of wastewater and description of wastewater source(s) of each outfall:
Outfall 001 —0.04 MGD. Domestic wastewater is treated by the existing contact
stabilization WWT facility which includes a bar screen, grit/surge tank followed by primary
clarification, aeration, re-aeration, final clarification, chlorination (tablet), dechlorination
(tablet), effluent flow measurement, and an aerated sludge holding tank.
PART III - OTHER PERTINENT INFORMATION
1. Regional sewer system availability: A municipal sewer line (City of Concord) is
approximately 150—200 ft. from this facility.
PART IV - EVALUATION AND RECOMMENDATIONS
The facility appeared to be adequately treating the wastewater(clear effluent no floatable
solids/foam) during the site visit. This facility is prone to flooding which has recently occurred. The
blower/motor units and electrical control box have been previously located on an elevated platform
to prevent damage from the previous flooding events; however, the remaining treatment plant
processes continue to be submerged.
The Park Manager (Permittee representative) is in the process of completing all of the City
of Concord's requirements for the connection to the City's sewer line. This process has been
difficult and costly for the Permittee and additional stipulations still need to be completed. No time-
line could be estimated for a completion date.
There has been no changes and/or modifications to this facility since the permit was last
issued. It is recommended that the subject Permit be renewed as requested.
Signature o eport Preparer ate
eate
Water Quality Regional Supervisor
hidsr\dsr12Wcoa.doc

Silver Maples Community
2812 Plantation Road
Concord, North Carolina 28027
704-786-5577/ 704-788-8945 Fax Number
May 24, 2013
Mr. Charles H. Weaver
NCDENR/DWQ/NPDES Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: Permit Renewal Application
NPDESPermit#NC0047091
Silver Maples Community WWTP
Cabarrus County
On behalf of Silver Maples Estates we hereby request re-newal
as is of permit # NC0047091.
Chester G. DeBoard Jr.
Manager
2812 Plantation Road
Concord, NC 28027

Silver Maples Community
2812 Plantation Road
Concord, North Carolina 28027
704-786-5577/704-788-8945 Fax Number
Sludge
When in the ORC's determination, solids leading has reached it's
peak and sludge thickening capabilities have been exhausted, a
third parry "pump and haul" contractor is retained to collect and
haul excess solids to ultimate disposal. Screenings such as
grease, are also collected and disposed of in the same manner.
We routinely retain L and L Environmental for these services.

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
Mail the complete application to:
N. C. DENR / Division of Water Quality / NPDES Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
NPDES Permit 000O q (�
If you are completing this form in computer use the TAB key or the up - down arrows to moue from one
field to the next. To check the boxes, click your mouse on top of the box. Otherwise,please print or type.
1. Contact Information:
Owner Name L Le,
Facility Name
Mailing Address pin_
City /?CAL &=ed
State / Zip Code �h , LC , �D
Telephone Number /(-Zal) 7
Fax Number �—
e-mail Address S[Wz�M ��, S t�i) _/ Q `_s 0 D
2. Location of facility producing discharge: C T
Check here if same address as above 9--
Street Address or State Road
City
State / Zip Code
County
3. Operator Information:
Name of the firm, public organization or other entity that operates the facility. (Note that this is not
referring to the Operator in Responsible Charge or ORC)
Name
Mailing Address
City
State / Zip Code n) Al g J/D
Telephone Number /�� Jl
Fax Number ( 7
e-mail Address Q m 4-
1 of 3 Form-D 11/12

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
4. Description of wastewater:
Facility Generating Wastewater(check all that apply):
Industrial ❑ Number of Employees
Commercial ❑ Number of Employees
Residential Number of Homes
School ❑ Number of Students/Staff
Other ❑ Explain:
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
/✓)D�i Iq VVIVk-.2— pp-Yu!
Number of persons served: �i�
5. Type of collection system
EVSeparate (sanitary sewer only) ❑ Combined (storm sewer and sanitary sewer)
6. Outfall Information:
Number of separate discharge points
Outfall Identifcation number(s) if)�
Is the outfall equipped with a diffuser? ❑ Yes U-No
7. Name of receiving stream(s) (NEW applicants:Provide a map shounng the exact location of each
outfall.j
8. Frequency of Discharge: Continuous ❑ Intermittent
If intermittent:
Days per week discharge occurs: Duration:
9. Describe the treatment system
List all installed components, including capacities,provide design remoual for BOD, TSS, nitrogen and
phosphorus. If the space provided is not sufficient, attach the description of the treatment system in a
separate sheet of paper.
�IZ�c t2�.�ilk
2 of 3 Form-D 11112

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow t4 �J.J�—MGD
Annual Average daily flow . I)�9 MGD (for the previous 3 years)
Maximum daily flow MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes D3:5No
12. Effluent Data
NEW APPLICANTS:Provide data for the parameters listed. Fecal Coliform, Temperature and pH shall be grab
samples,for all other parameters 24-hour composite sampling shall be used. If more than one analysis is reported,
report daily maximum and monthly average. If only one analysis is reported, report as daily maximum.
RENEWAL APPLICANTS: Prouide the highest single reading(Daily Maximum)and Monthly Average over
the past 36 months or parameters curre tly in your permit Mark other parameters `N/A".
Parameter Daily Monthly Units of
Maximum Average Measurement
Biochemical Oxygen Demand (BODs) M
Fecal Coliform M L
Total Suspended Solids
Temperature (Summer) o
Temperature (Winter) U G
pH 0
13. List all permits, construction approvals and/or applications:
Type Permit Number Type Permit Number
Hazardous Waste (RCRA) NESHAPS (CAA)
UIC (SDWA) Ocean Dumping(MPRSA)
NPDES (�SC2y Dredge or fill (Section 404 or CWA)
PSD (CAA) Other
Non-attainment program (CAA)
14. APPLICANT CERTIFICATION
I certify that I am familiar with the information contained in the application and that to the
best of my knowledge and belief such information is true, complete, and accurate.
Printed,name of Person Signing Title
L"6y7,.�cT/Pi sU,c�
M17 - 2-0/ 3
Signature of Apphcant Date
North Carolina General Statute 143-215.6 (b)(2) states: Any person who knowingly makes any false statement representation, or certification in any
application, record, report, plan,or other document files or required to be maintained under Article 21 or regulations of the Environmental Management
Commission implementing that Artide, or who falsifies, tampers with, or knowingly renders inaccurate any recording or monitoring device or method
required to be operated or maintained under Article 21 or regulations of the Environmental Management Commission implementing that Article, shall be
guilty of a misdemeanor punishable by a fine not to exceed$26,000,or by imprisonment not to exceed six months,or by both. (18 U.S.C.Section 1001
provides a punishment by a fine of not more than$25,000 or imprisonment not more than 5 years,or both,for a similar offense.)
3 of 3 form-D 11112